Ian Powell: An unresponsive Prime Minister and Health Minister to a best endeavour

I have expressed my concerns in these postings and other media outlets about the Government’s decision, without mandate or engagement with the health sector, to abolish district health boards (DHBs) in Aotearoa New Zealand’s public health system (thereby abandoning the longstanding democratic principle of subsidiarity between central and local government).

I have also expressed concern about the Government’s increasing drift towards a laissez-faire pandemic response since last October.

On 2 February I blended both concerns together in an email to Prime Minister Jacinda Ardern arguing that it was dangerous to disestablish DHBs in the midst of a pandemic. These concerns have subsequently greatly intensified with the onslaught of the highly transmissible Omicron variant.

In addition to throwing our health system, both community and hospital, into crisis it has led to a massive increase in mortalities; from around 50 prior to this year (over 21 months) to a further nearly additional 600 deaths to date this year.

Below is the text of my email:

Dear Prime Minister

I am writing to you in respect of the decision to abolish DHBs by 1 July as provided for in the Pae Ora (Healthy Futures) Bill currently before Parliament. You are probably aware that I was the Executive Director of the Association of Salaried Medical Specialists from April 1989 to December 2019.

This has given me the opportunity to observe and analyse several restructurings in Aotearoa, including what I regard as the best conducted and most effective, the Public Health and Disability Act 2000 which established the district health board system.

During this employment I have also had the opportunity to look at health systems internationally including the United Kingdom, Germany and other parts of Europe, Australia, and the United States. It also enabled me to meet and engage with the OECD, WHO and the World Medical Association.

You may aware that I am presently a freelance health systems commentator and blogger. What I have had published includes matters relevant to what I discuss below.

To avoid any ambiguity, I am not opposed to the whole of the Pae Ora Bill. I strongly support the proposals to establish both the Maori Health Authority and the new crown public health agency. In both cases these have been discussed and advocated in various forms for some time. They have not come from left-field. The latter was not in the Heather Simpson review of the health and disability system but the need for a public health agency has been discussed and debated over many years. In both cases the argument is not new, and their time has come.

The same can’t be said for the abolition of DHBs. It was not part of Labour’s election manifesto in 2020 (quite the opposite) and was not recommended by the Simpson review. Its announcement last April came as a complete surprise and there has been no opportunity for the public to be engaged with or sought a mandate from (the restrictive parliamentary process for the bill falls well short of this threshold).

It is important to recognise the role and purpose of DHBs. I say this as someone who has been more critical than most of some of their actions over two decades. Establishing DHBs meant establishing for the first time statutory bodies responsible for the health and well-being of geographically defined populations and integration between community (including general practice and aged residential care) and hospital care. [area health boards gradually established in the mid to late 1980s also had this objective but had insufficient time to develop it before being abolished by the National government in 1993]

This full responsibility across the spectrum of health has been a strength of our public health system since 2001. This includes the obligation to “regularly investigate, assess, and monitor the health status of its resident population”. Structurally, this has given New Zealand significant advantages over many other modern health systems where, for different reasons, community and hospital care are much less integrated by being more structurally separated.

The biggest difficulty has been uneven and inconsistent national leadership (structurally and politically) to provide the level of national cohesion needed. Much good has been achieved but much more potential unrealised. Responsibility for this rests much more within central government than DHBs.

In my assessment DHBs came under unfair criticism for the handling of the vaccine rollout. But I have looked closely at the international data which confirms that by they have done very well. Our fully vaccinated rate is one of the highest in the world. It was even higher than the European Union which had the massive advantage of being able to both negotiate as a powerful collective bloc with the monopolistic pharmaceutical companies and have within its membership vaccine producing countries.

The uniqueness of having statutory local structures responsible for geographically defined populations proved to be a major factor in this success. Despite having no control over supply DHBs were able to compensate for our big disadvantage as a small economy far away from vaccine producing countries.

Regrettably, earlier in the rollout, some DHBs were singled out for criticism. But the fact of the matter is that DHBs comparative milestone achievements ranked according to workforce size and population density. The bigger DHBs workforce and the denser their population, the sooner they achieved vaccination milestones. It was the DHBs with smaller workforces and lower population density because of rural communities that were comparatively slower.

As you will be acutely aware the effect of omicron is going to put the whole country’s health system under unprecedented dangerous pressure, especially our public hospitals. No longer will the impact be confined to a region. Transmission will be too high and fast to prevent increasing hospitalisations. This will likely increase mortality rates.

Hospitals are also likely to be bogged down by ‘long covid’ where the effects of the virus continue for weeks or months beyond the initial illness. This will leave our public hospitals unable to do much else than do their best for Covid-19 patients (sadly with compromises). This is made worse by an already overstretched and fatigued workforce. It is much more likely than not that omicron won’t be the last Covid-19 variant this year. Some of its successors will be less and others more virulent.

As you can see from my comments above, I believe abolishing DHBs is wrong and will be counter-productive. Losing statutory bodies that know their defined populations well compared with a national body (with or without regional branches) will set back the effectiveness of the health system. It is compounded by the fact that there is little idea other than ‘prototypes’ what will be the replacement for the community care functions of DHBs.

But, in addition, to do this during a pandemic is dangerous. It is dangerous for patients, for those that work in the health system (especially those involved in treatment), and it is dangerous electorally.

I strongly urge you to reconsider this decision. I’m confident that this could be messaged with integrity in a way that would not look like a backdown. In fact, the structure of DHBs is well-placed to better assist the effectiveness of both the Maori Health Authority and the crown public health agency.

I appreciate that you are far too busy to discuss this further directly with me but if one of your advisers or someone else on your behalf wish to do so I would welcome it…

Kind regards
Ian Powell

I did receive a prompt courteous acknowledgement from the Prime Minister’s office advising that this email had been forwarded on to Minister of Health Andrew Little who would reply to me directly.

Needless to say, nearly three months later, there has been no response from the Minister; not even a brief compilation of stock soundbites. Well, I tried. I have no sense of outrage because I had no sense of expectation. Back to the blogging.

Ian Powell is the editor of the health systems blog Otaihanga Second Opinion HERE, a health commentator, and a former Executive Director of the Association of Salaried Medical Specialists.